Basic Information
Provider Information | |||||||||
NPI: | 1598053225 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WASHBURN | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2124 14TH ST | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393014040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017033480 | ||||||||
FaxNumber: | 6017030124 | ||||||||
Practice Location | |||||||||
Address1: | 1056 HOLLAND AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | MS | ||||||||
PostalCode: | 393509121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016568545 | ||||||||
FaxNumber: | 6016563985 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2011 | ||||||||
LastUpdateDate: | 11/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 00152 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 04774800 | 05 | MS |   | MEDICAID |